Schizophrenia with prominent catatonic features: A selective review.

A widely accepted consensus holds that a variety of motor symptoms subsumed under the term 'catatonia' have been an integral part of the symptomatology of schizophrenia since 1896, when Kraepelin proposed the concept of dementia praecox (schizophrenia). Until recently, psychiatric classifications included catatonic schizophrenia mainly through tradition, without compelling evidence of its validity as a schizophrenia subtype. This selective review briefly summarizes the history, psychopathology, demographic and epidemiological data, and treatment options for schizophrenia with prominent catatonic features. Although most catatonic signs and symptoms are easy to observe and measure, the lack of conceptual clarity of catatonia and consensus about the threshold and criteria for its diagnosis have hampered our understanding of how catatonia contributes to the pathophysiology of schizophrenic psychoses. Diverse study samples and methodologies have further hindered research on schizophrenia with prominent catatonic features. A focus on the motor aspects of broadly defined schizophrenia using modern methods of detecting and quantifying catatonic signs and symptoms coupled with sophisticated neuroimaging techniques offers a new approach to research in this long-overlooked field.

Catatonic schizophrenia: a cohort prospective study.

BACKGROUND: In the 20th century, catatonia was usually deemed a subtype of schizophrenia. Recently, the nature and classification of catatonia are being reconsidered. This study is the first to describe catatonia using prospectively collected data and to examine how catatonic schizophrenia differs from, or resembles, other types of schizophrenia. METHODS: Data were analyzed in a cohort of 90,079 offspring followed from birth till ages 29-41 years. Proportional hazards models were used, calculating time to first psychiatric hospital admission, to compare risk factors for catatonic schizophrenia vs "other schizophrenia." RESULTS: Of 568 cases of schizophrenia, 43 (7.6%) had catatonic schizophrenia. The sexes were equally at risk for catatonic schizophrenia in contrast to other schizophrenia, for which the incidence was higher in males (1.70, 1.42-2.03, P < .0001). Advancing paternal age had no influence on the risk of catatonic schizophrenia in contrast to other schizophrenia, in which the risk to offspring of fathers age 35+ was 1.27 (1.03-1.57, P = .03) compared with those of younger fathers. Those with catatonic schizophrenia were somewhat more likely to have older mothers (aged 35+) (relative risk = 2.14, 0.85-5.54) while maternal age was not related to other schizophrenia. Both were equally affected by parental history of schizophrenia. Patients with catatonia were significantly more likely to attempt suicide (P = .006). CONCLUSION: Patients with catatonic schizophrenia show a somewhat different profile of risk factors from those with other types of schizophrenia in this cohort and are more likely to attempt suicide. This lends some support to the hypothesis that catatonic schizophrenia may have a distinct etiology.

Catatonia: a syndrome appears, disappears, and is rediscovered.

Catatonia is the psychiatric syndrome of disturbed motor functions amid disturbances in mood and thought first described in 1874. It was quickly found in 10% to 38% of psychiatric populations. After it was tied to schizophrenia as a type in the psychiatric classification, its recognition became increasingly limited and by the 1980s questions were asked as to where the catatonics had gone. The decline is largely owing to the change in venue for psychiatric practice from asylum to office, the rejection of physical examination, and the dependence on item rating scales for diagnosis. In the 1970s, broad surveys again showed that catatonia was as common as before among patients with mania and depression, and as a toxic response to neuroleptic drugs. The latter recognition, that the neuroleptic malignant syndrome is the same syndrome as malignant catatonia, and is effectively treated as such, sparked a renewed interest. Clinicians developed rating scales to identify the catatonia syndrome and applied the immediate relief afforded by a barbiturate or a benzodiazepine as a diagnostic test, the lorazepam test. Effective treatments were described as high doses of benzodiazepines and electroconvulsive therapy (ECT). Surveys using catatonia rating scales showed catatonia to have many faces. Catatonia is presently limited to a type of schizophrenia in the psychiatric classification. Its recognition as a disorder of its own, such as delirium and dementia, should now be recognized. This experience reinforced the utility of the medical model for diagnosis. An application for melancholia is described.

Catatonic syndrome: importance of detection and treatment with lorazepam.

BACKGROUND: A resurgence of interest has led to renewed attempts to clarify the concept and treatment of catatonia. METHOD: A large prospective study was conducted to estimate the incidence of catatonic syndrome in 138 consecutive psychiatric patients admitted to a general hospital in India, to demarcate the common symptom presentations and its response to intravenous benzodiazepines. Patients were screened using the Bush Francis Catatonia Screening Instrument. Patients with two or more signs on the Instrument were subsequently administered intravenous lorazepam and their response was rated on the Bush Francis Catatonia Rating Scale. RESULTS: Catatonic syndrome was found in 11% of patients with a wide variety of diagnoses, especially schizophrenia. Mutism (87.5% incidence) was the most common symptom. A significant proportion (93%) of these patients showed a marked immediate response to lorazepam, with 75% showing sustained improvement. CONCLUSIONS: Catatonic syndrome is common, often undiagnosed, and quickly responsive to treatment, irrespective of the diagnosis. It needs to be identified and actively treated with benzodiazepines to minimize distress, and facilitate diagnosis and treatment. Most patients also need additional treatment for the underlying psychiatric condition.

Epileptic seizures superimposed on catatonic stupor.

PURPOSE: Some patients with nonconvulsive status epilepticus are known to exhibit catatonic stupor. Thus it is necessary to rule out ictal catatonia by electroencephalography in patients with catatonic stupor. However, few reports are available on epileptic seizures superimposed on catatonic stupor. METHODS: We report three cases of epileptic seizures superimposed on psychiatric catatonic stupor without a prominent predisposing factor, including high fever or encephalitis. None of the patients had a personal or family history of neurologic disease, including epilepsy. RESULTS: In all three patients, catatonic stupor persisted after resolution of the epileptic seizures with administration of phenytoin. In two of the three patients, catatonic stupor resolved with electroconvulsive therapy, which caused no marked adverse effects. CONCLUSIONS: Because it is possible that catatonic stupor itself predisposes patients to the development of epileptic seizures, electroencephalographic examinations in patients with catatonic stupor are indispensable for early recognition not only of nonconvulsive status epilepticus but also of epileptic seizures superimposed on catatonic stupor. Electroconvulsive therapy deserves consideration when catatonic stupor persists after resolution of epileptic seizures.

Associations between serum brain-derived neurotrophic factor levels and clinical phenotypes in schizophrenia patients.

This study investigated serum brain-derived neurotrophic factor (BDNF) protein levels in schizophrenia patients and healthy control subjects and schizophrenia patients with various clinical phenotypes. During a 1-year period, 126 schizophrenic patients and 96 healthy control subjects were recruited. Serum BDNF protein levels were measured using an ELISA Kit. Psychiatric diagnoses were made according to DSM-IV criteria. One-way analysis of variance (ANOVA) showed no significant differences in serum BDNF protein levels between schizophrenia and healthy normals. Additionally, no significant differences existed in BDNF levels between schizophrenia patients for the following variables: with/without a suicide attempt; antipsychotic drug use, family tendency and disease onset before and after 25 years old. However, patients with catatonic schizophrenia had lower serum BDNF protein levels than patients with paranoid or residual schizophrenia. These analytical results suggested that BDNF might play an important role in the clinical subtypes of schizophrenia, but it needed further investigation in future.

Continuation electroconvulsive therapy for relapse prevention in middle-aged and elderly patients with intractable catatonic schizophrenia.

The authors have previously studied the short-term effect of the first acute electroconvulsive therapy (ECT) course (phase 1 study) on intractable catatonic schizophrenia and the 1-year relapse rate after response to the acute ECT (phase 2 study) in middle-aged and elderly patients. Results indicated that, although acute ECT has an excellent short-term effect, the 1-year relapse rate after response to acute ECT is high despite the use of continuation neuroleptics. In the present prospective study the effect was explored of continuation ECT with neuroleptics on the prevention of relapse after response to a second acute ECT course in the relapsed participants of the phase 2 study. The present study included seven consecutive patients > 45 years of age with catatonic schizophrenia (Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) who relapsed (despite the use of neuroleptics) within 1 year after response to the first acute ECT course, and then responded to the second acute ECT course. The patients were given continuation ECT combined with neuroleptics; four ECT sessions at weekly intervals, then four ECT sessions every 2 weeks, then three ECT sessions every 4 weeks. Clinical symptoms were evaluated by means of the Brief Psychiatric Rating Scale (BPRS) weekly for 48 weeks or until relapse. Relapse was defined as a BPRS score of at least 37 for 3 consecutive days. Three out of the seven patients (42.9%) had a sustained response to ECT during the 1-year follow-up period. In the seven patients the probability of relapse within 1 year under treatment with neuroleptics alone (phase 2 study) was statistically higher than that under continuation ECT combined with neuroleptics (present study). No statistical differences were seen between the phase 2 study and the present study in the severity of psychiatric symptoms, global social function, the number of acute ECT sessions or the dosage of neuroleptics. No patient experienced a severe cognitive or physical adverse effect resulting from continuation ECT. Continuation ECT with neuroleptics is an efficacious and safe treatment for maintaining a response in middle-aged and elderly patients with intractable catatonic schizophrenia who have relapsed after a positive response to acute ECT despite the use of continuation neuroleptics.

Clinical relevance of chronic catatonic schizophrenia in children and adolescents: evidence from a prospective naturalistic study.

The paper examines the phenomenology, diagnosis, and course of catatonia in children and adolescents. From 1993 to 2003, 21 boys and 9 girls, aged 12 to 18 years, were admitted for a catatonic syndrome (0.6% of the total inpatient population). Phenomenology and associated diagnoses were similar to those reported in the adult literature but relative frequency differed, with schizophrenia being the most frequent diagnosis. Comparison of patients with schizophrenia (n=17) to those with other diagnoses (n=13) showed that the two groups differed in terms of sex ratio, type of onset and phenomenology of catatonic symptoms, duration of hospitalization, and severity at discharge. Using discriminant function analysis, the combination of three clinical variables--male gender, duration of catatonic episode, and severity at discharge--correctly classified 100% of cases in the schizophrenia group. Catatonia is an infrequent but severe condition in young people, and is usually associated with schizophrenia. There is a need for research in the field of catatonic schizophrenia in adolescents as it appears to be a clinically relevant but understudied subgroup.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia'): I. Demographic and clinical correlates in the chronic phase.

This study set out to determine the frequency of catatonic syndrome in chronic schizophrenia and its association with sociodemographic, clinical, and treatment variables. A cross-sectional assessment of a randomly selected cohort of patients (n=225; mean age=42+/-7 years; mean length of illness=20.4+/-7.5 years) with DSM-IV schizophrenia was employed using standard rating instruments for catatonia, drug-induced extrapyramidal symptoms (EPS), and psychotic, depressive, and obsessive-compulsive symptoms. Using a rather narrow definition of catatonia [the presence of four or more signs/symptoms with at least one having a score '2' or above on the Bush-Francis Catatonia Rating Scale (BFCRS)], 72 subjects (32%) met the criteria for the catatonia group (mean number of catatonic signs/symptoms=5.9+/-2.0; mean sum score of 8.7+/-3.4 on the BFCRS). The frequency distribution of catatonic signs/symptoms in the catatonic group and in the whole sample was very similar, with mannerisms, grimacing, stereotypes, posturing, and mutism being the most frequent. In the logistic regression analysis, catatonic subjects had a significantly earlier age of onset, more negative symptoms, and were more likely to receive benzodiazepines than their noncatatonic counterparts. In multiple regression analysis, the severity of catatonia as indicated by the sum score of BFCRS was predicted only by earlier age of onset and negative symptoms. Using relatively narrow criteria, this study confirmed that, if methodically assessed, catatonic signs and symptoms are prevalent in patients with chronic schizophrenia. Catatonia can be differentiated from EPS. Catatonic features indicate a generally poor prognosis in the chronic phase of schizophrenia.

Catatonic features noted in patients with post-partum mental illness.

The purpose of the present study was to investigate the prevalence, distribution of psychiatric diagnoses, and treatment responses of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung in Taiwan. During a 1 year period a total of 636 Taiwanese women received psychiatric consultation on their visits to the emergency room. Fifteen of these were noted to have post-partum mental illnesses. All subjects were followed up for a minimum of 3-6 months. The prevalence of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung was 2.4% (15/636). The distribution of psychiatric diagnoses according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria included eight cases of major depressive disorders (53.3%), three cases of bipolar I disorder (20%), three cases of schizophrenia (20%), and one case of psychotic disorder due to a general medical condition (6.7%). Four subjects manifested catatonic features. Of these four, three had complete remission in catatonic symptoms after receiving intramuscular injection of lorazepam. The fourth subject died of multiple medical diseases. The treatment results suggest that most of the clinical presentations in patients with post-partum mental illness could be relieved by antipsychotics, mood stabilizers or antidepressants. In addition, it was found that intramuscular injection of lorazepam was also effective in patients with catatonic features and post-partum depression or psychosis.

[The frequency of diagnosis of catatonic schizophrenia in hospitals in Lubliniec (1894-1932, 1934-1936, 1970-1999) and Boleslawiec (1958-1999)]. / Czestosc rozpoznan schizofrenii katatonicznej w szpitalach w Lublincu (1894-1932, 1934-1936, 1970-1999) i Boleslawcu (1958-1999).

AIM: The analysis of the data from the psychiatric hospitals in Lubliniec (1894-1932, 1934-1936, 1970-1999) and Boleslawiec (1958-1999) proved a decrease in frequency of diagnosis of catatonic schizophrenia, what could testify to a decrease in morbidity with this form of schizophrenia. METHOD AND RESULTS: Basing on the facts from scientific literature there was ascertained that the decrease in frequency of diagnosis of catatonic schizophrenia is connected with following causes: firstly, with the changes in nozology, secondly, with the introduction of a new form of therapy and finally, with the fact that here psychological and sociological factors exist which eliminate catatonia as the most expressive form of schizophrenia.

Esquizofrenia catatónica, complicaciones médicas asociadas e indicación de terapia electroconvulsiva: a propósito de un caso clínico / Catatonic schizophrenia: associated medical complications and indication for electroconvulsive therapy. A case report

El diagnóstico de catatonía, como subtipo de esquizofrenia, se basa en unos criterios diagnósticos clínicos definidos. No obstante, no existe una explicación fisiopatológica para este proceso, que desde su origen se describió como de base cerebral, llegando a plantearse la catatonía como un síndrome donde diversas enfermedades psiquiátricas y médicas podrían estar implicadas. Cuando el estudio se centra en ésta como parte de las esquizofrenias, se observa un descenso llamativo en su diagnóstico. Resulta evidente la gravedad de estos procesos, presentando con frecuencia complicaciones médicas que ponen en grave riesgo vital al paciente. La utilización en estos casos de terapia electroconvulsiva (TEC) debe ser de primera elección, no sólo por la magnitud clínica, sino por las complicaciones médicas asociadas y la imposibilidad, en muchos casos, del tratamiento con psicofármacos. A continuación se presenta un caso clínico de episodio catatónico en paciente de edad avanzada con esquizofrenia crónica, donde las complicaciones médicas asociadas hicieron de la TEC la indicación primordial. (AU)

Catatonic schizophrenia has a shorter pre-hospitalisation interval than other types of schizophrenia.

The time elapsed between the first onset of symptoms and the onset of first hospitalisation was analysed in 355 participants diagnosed with paranoid, simple, hebephrenic and catatonic schizophrenia and shizoaffective disorder. The real onset of the disease was assessed from interviews with reliable relatives and by reviewing medical records in general practices and out-patient psychiatric services. In 184 patients a family history of schizophrenia was identified. A positive family history was found to significantly increase the interval preceding first hospitalisation in all analysed types, except in catatonic schizophrenia. Possible reasons causing this prolongation are discussed, as well as repercussions of the results to studies using age of first hospitalisation as the leading indicator.

Are we witnessing the disappearance of catatonic schizophrenia?

The decrease in the frequency of diagnosed catatonic subtypes among schizophrenic disorders as a whole during the last 50 years has long been regarded as an established fact. Until now the factors responsible for this development have been under discussion. As it is not clear if there is a true decrease or an ostensible one due to other factors such as changed diagnostic habits or neuroleptic treatment, we examined 174 consecutively admitted schizophrenic patients from three different psychiatric institutions diagnosed according to DSM-IV and Leonhard's criteria. It turned out that-depending on the diagnostic system-the rates of diagnosed catatonias were 10.3% (DSM-IV) and 25.3% (Leonhard's criteria). Comparison of the two original Leonhard cohorts (1938 to 1968, 1969 to 1986) with our own (1994 to 1999) shows a decrease in the frequency of catatonias from 35% to 25%, which-albeit statistically significant-is much less pronounced than in studies that used a narrower definition of catatonia. Here, besides sociocultural developments, the use of neuroleptics seems to effect the decrease in the frequency of catatonias in two ways: on one hand, they cause a decrease of hyperkinesia, excitement, or impulsivity; while on the other hand, they themselves produce motor abnormalities like rigidity, effects that favor the attribution of motoric symptoms to neuroleptics.

Catatonic schizophrenia in Croatia.

A representative sample of schizophrenic subjects was collected for epidemiological and clinical follow-up in 1972 from the pool of 8069 patients registered in the Croatian Psychotics Case Register (CPCR). This sample comprised 402 patients (207 males and 195 females), who were followed up until 1990/91. The diagnosis of schizophrenia, catatonic type according to ICD-8 (V/295.2), was made in 59 cases (14.7%; 28 males, 31 females) at least once in the course of the follow-up. This study presents data concerning the diagnostic instability of the catatonic subtype during the long-term follow-up. As subtype diagnoses were frequently changed over the course of illness, at the end of the follow-up, the diagnosis of catatonic schizophrenia was only confirmed in 11 (18.6%) cases. Positive family history of psychosis was found in 44.1% of catatonic patients, a percent significantly greater than the corresponding figure for all non-catatonic schizophrenic subtypes combined (20.1%). This study provides preliminary evidence that the catatonic subtype of schizophrenia is a separate diagnostic entity with a high familial loading.

Parent-of-origin effect and evidence for differential transmission in periodic catatonia.

In a family study involving 83 probands with periodic catatonia a subtype of DSM IIIR schizophrenia, we reported an age-specific morbidity risk of 26.9% in first-degree relatives with homotypical psychoses and genetic anticipation indicating a possible major gene effect. Paternal transmission was associated with a trend for a younger age at onset in probands compared to that observed in the case of maternal transmission (P = 0.099). If this can be confirmed in a larger sample and then replicated, there would be evidence for the occurrence of a parent-of-origin effect. Such an observation may indicate that a paternally imprinted locus acts on periodic catatonia. Among the non-genetic mechanisms that may modify the penetrance of the disease, paternal affection did lead to a decrease in male offspring (P = 0.007) and maternal affection showed an increased frequency of non-affected male offspring (P = 0.021). We therefore propose that parent-of-origin effects as well as prenatal mortality and psychosocial factors need further investigation in the periodic catatonia subtype of schizophrenia.

Gender differences in the frequency of schizophrenic subtypes in unselected hospitalized patients.

The phenotypic expression of the subtypes of schizophrenic disorders was studied in relationship to their relative frequency and the gender composition within each subtype using 374 successive DSM-III-R diagnosed schizophrenic patients. Two hundred and twenty-six of them were first admissions to a hospital. They were all diagnosed independently by three reviewers. While in the paranoid, the undifferentiated and the disorganized subtypes there was no significant difference between men and women, in the residual and the catatonic subtypes the frequency of men was more than three times greater than that of women. Among the 226 first admissions the frequency of the residual subtype was significantly lower than in the multiple admissions. The preponderance of male schizophrenic patients within the residual subtype indicates that they end up into this subtype, more frequently than women schizophrenic patients, whereas the greater preponderance of men in the catatonic subtype appears to reflect an intrinsic characteristic of this subtype.

Fatal pulmonary embolism in the catatonic syndrome: two case reports and a literature review.

BACKGROUND: Catatonia is associated with excess early mortality when it is unrecognized or inadequately treated. The characteristics of the lethal catatonia subtype are now well described, but the excess mortality of the remaining patients with catatonic syndrome, particularly from pulmonary embolism, appears to be inadequately recognized. The fatal risk of the catatonic syndrome is reviewed. METHOD: Two new case reports of sudden death from pulmonary embolism in catatonic syndrome are presented. The world literature on morbidity, mortality, and pulmonary embolism in catatonia was reviewed by a search of MEDLINE and PsychInfo from 1966 to the present. Additional older references were discovered by screening bibliographies from articles produced by the searches. RESULTS: Twenty cases of autopsy-confirmed pulmonary embolism were found in patients with catatonic syndrome. Catatonic patients were more likely to die of pulmonary embolism and die earlier than patients with other types of schizophrenia. Death from pulmonary embolism did not occur until after the second week of catatonic symptoms and often occurred without warning. CONCLUSION: Risk of a fatal pulmonary embolism is inherent in persistent catatonic symptoms and may explain the observed excess early mortality. Prompt resolution of the catatonic syndrome with benzodiazepines, barbiturates, or electroconvulsive therapy is the best way to reduce risk of pulmonary embolism. The prophylactic value of physical therapy or anticoagulation merits further investigation. Despite the absence of controlled trials of treatment effectiveness, the catastrophic outcome of acute pulmonary embolism warrants early and vigorous intervention in catatonic patients.

Outcome and family study of the subtypes of schizophrenia in the west of Ireland.

OBJECTIVE: The authors sought to clarify differences in outcome and familial psychopathology among the classical subtypes of schizophrenia. METHOD: In the epidemiologically based Roscommon Family Study, personal interviews were conducted with 88% of traceable living probands (N = 415) an average of 16 years after illness onset and with 86% of traceable living first-degree relatives (N = 1,753). Probands meeting the DSM-III-R criteria for schizophrenia were subtyped by DSM-III-R and ICD-9. RESULTS: By both diagnostic systems, age at onset differed significantly across subtypes, being earliest in the subjects with the hebephrenic and catatonic subtypes and latest in the paranoid subjects. The probands with the paranoid subtype had substantially better outcome, especially in occupational functioning and capacity for self-care. The DSM-III-R criteria for paranoid schizophrenia were considerably more successful than the ICD-9 criteria in selecting good-outcome cases. Neither the risk for schizophrenia nor the risk for schizophrenia spectrum disorders significantly differed in relatives as a function of the proband subtype. The subtypes of schizophrenia did not "breed true" within families. CONCLUSIONS: Paranoid schizophrenia, especially when narrowly defined, as in DSM-III-R, has a substantially better outcome than other subtypes. From a familial perspective, 1) paranoid schizophrenia is not a milder form of schizophrenia and 2) catatonic schizophrenia is probably closely related to typical schizophrenia. The subtypes of schizophrenia are not, from a familial perspective, etiologically distinct syndromes.

First admission schizophrenia: clinical manifestation and subtypes.

This paper describes the clinical manifestations and classification of schizophrenia in Singapore. The subjects were all first admission to Woodbridge Hospital in 1975. They were followed up 5, 10 and 15 years later. There were 423 patients. Of these, 17% had no delusions or hallucinations and 14% presented with only negative and withdrawn behaviour. They can be subdivided into four subtypes: paranoid, hebephrenic, "catatonic" and simple. Follow-up study showed that the percentage of full, partial and no recovery remained the same at around 30%, 30% and 40% at the end of 5, 10 or 15 years. The paranoid subtypes had best outcome and the simple had the worst outcome. Bleuler's criteria and his subtypes of schizophrenia are accepted by most psychiatric textbooks. These criteria did not include behavioural disturbances which are the commonest manifestations in this study. Other follow-up studies confirmed that paranoid patients have the best long-term outcome.